Antibiotics, Topical
PDL Reference Documents
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation & Updates |
|---|---|---|---|---|---|
| bacitracin | BACITRACIN | OINT. (G) | Y | ||
| bacitracin | BACITRAYCIN PLUS | OINT. (G) | Y | ||
| bacitracin | BACITRACIN | OINT. (G) | Y | ||
| bacitracin zinc | BACITRACIN ZINC | OINT. (G) | Y | ||
| bacitracin zinc | ANTIBIOTIC | OINT. (G) | Y | ||
| bacitracin zinc | BACITRACIN ZINC | OINT. (G) | Y | ||
| bacitracin zinc | ANTIBIOTIC | OINT. (G) | Y | ||
| bacitracin zinc/polymyxin B | POLY BACITRACIN | OINT. (G) | Y | ||
| bacitracin zinc/polymyxin B | DOUBLE ANTIBIOTIC | OINT. (G) | Y | ||
| bacitracin zinc/polymyxin B | POLYSPORIN | OINT. (G) | Y | ||
| bacitracin zinc/polymyxin B | DOUBLE ANTIBIOTIC | OINT. (G) | Y | ||
| bacitracin zinc/polymyxin B | POLY BACITRACIN | OINT. (G) | Y | ||
| bacitracin zinc/polymyxin B | WAL-SPORIN | OINT. (G) | Y | ||
| bacitracin/polymyxin B sulfate | BACITRACIN/POLYMYXIN | OINT. (G) | Y | ||
| bacitracin/polymyxin B sulfate | BACITRACIN/POLYMYXIN | OINT. (G) | Y | ||
| gentamicin sulfate | G-MYTICIN | CREAM (G) | Y | ||
| gentamicin sulfate | GENTAMICIN SULFATE | CREAM (G) | Y | ||
| mupirocin | CENTANY | OINT. (G) | Y | ||
| mupirocin | MUPIROCIN | OINT. (G) | Y | ||
| neomycin/bacitracin/polymyxinB | TRIPLE ANTIBIOTIC | OINT. (G) | Y | ||
| neomycin/bacitracin/polymyxinB | FIRST AID ANTIBIOTIC | OINT. (G) | Y | ||
| neomycin/bacitracin/polymyxinB | ANTIBIOTIC | OINT. (G) | Y | ||
| neomycin/bacitracin/polymyxinB | FIRST AID ANTIBIOTIC | OINT. (G) | Y | ||
| neomycin/bacitracin/polymyxinB | NEOSPORIN | OINT. (G) | Y | ||
| neomycin/bacitracin/polymyxinB | TRIPLE ANTIBIOTIC | OINT. (G) | Y | ||
| neomycin/bacitracin/polymyxinB | TRIPLE ANTI | OINT. (G) | Y | ||
| bacitracin | BACITRACIN | PACKET | N | ||
| bacitracin zinc | BACITRACIN ZINC | OINT PACK | N | ||
| gentamicin sulfate | GENTAMICIN SULFATE | OINT. (G) | N | ||
| mupirocin | CENTANY AT | KIT | N | ||
| mupirocin calcium | MUPIROCIN | CREAM (G) | N | ||
| neomycin sulf/polymyxin B sulf | ANTIBIOTIC | CREAM (G) | N | ||
| neomycin sulfate | NEOMYCIN SULFATE | OINT. (G) | N | ||
| neomycin/bacitracin/poly/lido | TRIPLE ANTIBIOTIC W/LIDOCAINE | OINT. (G) | N | ||
| neomycin/bacitracin/polymyxinB | TRIPLE ANTIBIOTIC | OINT PACK | N | ||
| neomycin/polymyxin B/pramoxine | ANTIBIOTIC PLUS | CREAM (G) | N | ||
| neomycin/polymyxin B/pramoxine | ANTIBIOTIC PLUS PAIN RELIEF | CREAM (G) | N | ||
| neomycn/bacitrc/polymyx/pramox | TRIPLE ANTIBIOTIC-PAIN RELIEF | OINT. (G) | N | ||
| neomycn/bacitrc/polymyx/pramox | TRIPLE ANTIBIOTIC PLUS | OINT. (G) | N | ||
| ozenoxacin | XEPI | CREAM (G) | N |